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Three Part Question

In [alert asymptomatic blunt trauma patients] is [cervical spine radiography] necessary to [exclude bony injury to the cervical spine]?

Clinical Scenario

A 46 year old man is brought to hospital after a road traffic accident, involving a rear end shunt, to "get checked out". He is fully alert and co-operative. You are aware that many people advise x-rays in all patients to exclude cervical spine injury. You wonder whether it is really necessary.

Search Strategy

Medline 1996-10/04 using OVID interface.
[exp cervical vertebrae OR exp spinal cord injuries OR exp spinal fractures OR exp spinal injuries OR cervical spine injury.mp] AND [exp x-rays OR x-rays.mp OR exp radiography OR radiograph$.mp OR cervical radiograph$.mp] AND [exp prospective studies OR prospective studies.mp] LIMIT to human AND English.

Search Outcome

240 papers were identified of which 8 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Roberge RJ et al, 1988, USA	467 blunt trauma patients undergoing c-spine x-ray	Prospective	Cervical spine injury	In alert patients cervical spine pain. Sensitivity 100% (54-100). Cervical spine tenderness, sensitivity 100% (54-100)
Roberge RJ and Wears RC, 1992, USA	480 blunt trauma patients undergoing c-spine x-ray	Prospective	Cervical spine injury	Clinical examination in alert patients, sensitivity 93% (75-100). Negative predictive value 98.7% (94.9-100)	Not all patients included Total number of blunt trauma victims not known No search for misses
Hoffman JR et al, 1992, USA	974 blunt trauma patients who had x-ray performed and data sheet filled in	Prospective	Cervical spine fracture	Alert patient with no intoxication, midline neck tenderness or distracting injury, sensitivity = 100%	Not all patients included in the study No search for misses
Velhamos GC et al, 1996, USA	549 blunt trauma patients Alert, not intoxicated and no neck pain Brought to hospital in hard collar	Prospective	Cervical spine injury or fracture	All patients had normal c-spine examination. No c-spine fractures or cord injuries found
Gonzalez RP et al, 1999, USA	2176 consecutive blunt trauma patients GCs 14 or 15	Prospective	Cervical spine injury	Clinical examination 91% sensitivity for CSI; Lateral c-spine screen (xr, swimmers CT) 61% sensitivity for CSI	Includes intoxicated patients No power calculation No search for misses
Hoffman JR et al, 2000, USA	34,069 patients having cervical spine x-ray after blunt trauma 21 Centres	Prospective	Clinically significant cervical spine injury	Decision instrument (alert with no evidence of intoxication, no midline cervical tenderness and no neurological deficit or distracting injury). Sensitivity of 99.6% (98.6-100) for significant injury, negative predictive value 99.9% (98.8-100)
Stiell IG et al. Dec 2003 Canada	Alert trauma patients attending 9 Canadian emergency departments.	Prospective Diagnostic Cohort Study	Incidence of clinically important cervical spine injuries	160 out of 8283 patients (2.0%) had clinically important injury	845 patients (10.2%) did not have range of motion evaluation.
				Sensitivity results: Canadian rules 99.4% versus NEXUS rules 90.7% (p<0.001)
				Specificity: Canadian rules 90.7% versus NEXUS 36.8% (p<0.001)
			Radiography rates	Canadian rules - 55.9% versus NEXUS 66.6% (p<0.001).
			Important injuries missed	Canadian rules- 1 patient, NEXUS rules - 16 patients.
Bandiera G et al. 2003 Canada	Alert, stable, adult patients with a GCS of 15 and trauma to the head and neck.	Prospective multi-centre cohort study.	Clinically important spinal injuries	64 out of 6265 patients (1%)	Not all patients had cervical spine radiography.
			Area under ROC curve for predicting cervical spine injury	Physician judgement - 0.85 (95% CI 0.80 to .089), Canadian rules 0.91 (95% CI 0.89 to 0.92) (p<0.05).
			Sensitivity	Physician judgement 92.2% versus Canadian rules 100% (p<0.001)
			Specificity	Physician judgement 53.9% versus Canadian rules 44.0% (p<0.001)

Comment(s)

Several prospective studies have been done on this topic, and all reached roughly the same conclusion. However, in this potentially disastrous situation all authors are keen to suggest that any clinical decision strategy can never be 100% sensitive and should be used on an individual patient basis rather than as an unbendable rule.

Clinical Bottom Line

The studies show that Canadian c-spine rules appear to be more sensitive and specific than the NEXUS criteria for clinical clearnance of the cervical spine. Patients who satisfy the Canadian c-spine rules for clinical clearance of the neck do not need to have cervical spine radiography.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Roberge RJ, Wears RC, Kelly M et al. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. J Trauma 1988;28(6):784-8.
2. Roberge RJ and Wears RC. Evaluation of neck discomfort, neck tenderness and neurological deficits as indicators for radiography in blunt trauma victims. J Emerg Med 1992;10(5):539-44.
3. Hoffman JR, Schriger DL, Mower W et al. Low risk criteria for cervical spine radiography in blunt trauma. Ann Emerg Med 1992;21(12):1454-60.
4. Velhamos GC, Theodorou D, Tatevossian R et al. Radiographic cervical spine evaluation in the alert asymptomatic blunt trauma victim: much ado about nothing. J Trauma 1996;40(5):768-74.
5. Gonzalez RP, Fried PO, Bukhalo M et al. Role of clinical examination in screening for blunt cervical spine injury. J Am Coll Surg 1999;189(2):152-7.
6. Hoffman JR, Mower WR, Wolfson AB et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilisation Study Group. NEJM 2000;343(2):94-9.
7. Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH et al. The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma. New Eng J Med 2003;349(26):2510-8.
8. Bandiera G, Stiell IG, Wells GA, De Maio V, Vandemheen KL et al. The Canadian c-spine rule performs better than unstructured physician judgement. Ann Emerg Med 2003;42:395-402.